Can your doctor dismiss you from his/her practice – legally?

Julia Draznin Maltzman, MD and Bruce D. Armon, Esquire The Abramson Cancer Center of the University of Pennsylvania

Dismissed

Unhappy patients can seek another medical opinion or find another doctor without retaliation by the physician. This is our fundamental right as consumers in a capitalist system. But what about your doctor's rights? Can he or she dismiss you from his/her practice? Physicians take an oath to always act in the best interest of their patients, and they are expected to abide by it. In fact, doctors, unlike patients, face legal and ethical restrictions before they may end relationships with patients.

If polled, virtually every doctor would admit to having difficult encounters with abusive, deceitful, threatening, and/or non-compliant patients in their practice. Furthermore, each of these doctors would likely express some relief if these types of patients would voluntarily leave the practice and seek medical care elsewhere. However, any attempt by the doctor to sever the doctor-patient relationship is a tricky undertaking.

In general, the relationship between a provider of a service and the consumer is considered to be voluntary: for example, a store merchant and a store customer, or a restaurant owner and a patron. Either party could terminate its relationship at any point. However, the relationship between a doctor and a patient is clearly considered to be different.

Initially, common law stated that a doctor did not have an obligation to treat a particular patient as long as a previous relationship between the doctor and this patient did not exist. This was referred to as the "no duty" rule, and it even extended to a doctor's right to refuse to treat an individual in need of emergency care, as long as there was no prior relationship between the doctor and the patient. This "no duty" rule was based on a contract theory: to create a doctor/patient relationship and the doctor's duty to treat, both parties had to voluntarily consent. To establish a duty-bound relationship, therefore, the doctor must affirmatively act in a manner suggesting an intention to treat a patient.

Once a patient has terminated the doctor/patient relationship, the doctor is not legally obligated to re-accept the patient -- even for the same condition for which the doctor initially treated the patient. In 1987, a case debating this issue was tried in a federal court in Mississippi. The court confirmed that the physician's actions were legal, although it did rule that the university medical center was required to continue providing treatments to the patient, provided that the patient continually complied with certain conditions. The relevant facts are as follows:

Michael Brown suffered from renal disease his entire adult life. According to the court's opinion, Mr. Brown displayed an inability to adapt to the constraints imposed by his condition and an almost complete failure to cooperate with his dialysis treatment regimen. Furthermore, Mr. Brown often mistreated and victimized the medical center staff as well as other patients. Despite knowing the severe health risks of missing his dialysis treatments, he was often late for appointments, or else missed them entirely. Mr. Brown then moved out of the community and began receiving treatment elsewhere, though his difficult behavior with staff and physicians at the new facility reportedly did not change.

Fifteen months later, Mr. Brown returned to his prior residence and sought continued dialysis treatment from the initial academic medical center and the original treating physician. When refused treatment by both, Mr. Brown filed suit.

There was a split decision for the institution and the individual physician. The court ruled that the local medical center was obligated to provide treatment to Mr. Brown because it had received federal funding. The physician argued that if he were required to begin treating Mr. Brown again, such a decision would violate the prohibition against involuntary servitude of the 13th amendment of the U.S.

Constitution. The court agreed with the doctor and noted that the doctor had treated Mr. Brown until Mr. Brown voluntarily terminated the doctor-patient relationship. The court noted that when Mr. Brown returned to the community, the doctor has "simply chosen not to accept [Mr.] Brown as a patient again. This decision is neither contrary to the law nor unethical."

Once a doctor/patient relationship is established, a doctor generally has the duty to continue to provide care to the patient until: (1) the relationship is terminated by the mutual consent of the patient and doctor; (2) the dismissal of the doctor by the patient; (3) the clinical services of the doctor are no longer required by the patient; or (4) the doctor properly withdraws from the doctor/patient relationship.

Your doctor has both ethical and legal obligations to provide services to you as long as you need them. If your doctor does not appropriately end the relationship, he or she could be liable for a claim of patient abandonment.

According to the American Medical Association (AMA), abandonment is defined as "the termination of a professional relationship between physician and patient at an unreasonable time and without giving the patient the chance to find an equally qualified replacement." However, to prove abandonment, the patient must show more than a simple termination of a patient-doctor relationship. According to the AMA, the plaintiff must prove that the doctor ended the relationship at a critical stage of the patient's treatment without good reason or sufficient notice to allow the patient to find another doctor, and that the patient was injured as a result. Usually, expert evidence is required to establish whether termination did in fact happen at a critical stage of treatment.

The AMA's Council on Ethical and Judicial Affairs has adopted a policy regarding the termination of the doctor-patient relationship. Opinion

8.115 states, "Physicians have an obligation to support continuity of care for their patients. While physicians have the option of withdrawing from a case, they cannot do so without giving notice to the patient, the relatives, or responsible friends sufficiently long in advance of withdrawal to permit another medical attendant to be secured."

How can a doctor fire me?

There are certain steps that a doctor should undertake to terminate a doctor/patient relationship. According to the AMA white paper entitled "Ending the Patient-Physician Relationship," these typically include:

Providing the patient with a brief explanation for terminating the relationship (this should be a valid reason, for instance: non-compliance, failure to keep appointments);

Agreeing to continue to provide treatment and access to services for a reasonable period of time, such as 30 days, to allow a patient to secure care from another physician (a physician may want to extend the period for emergency services);

Providing resources and/or recommendations to help a patient locate another physician of like specialty; and

Offering to transfer records to a newly-designated physician upon signed patient authorization to do so.

Documentation

Proper documentation is essential. A doctor's dismissal of a patient can be appropriate if there are multiple well-documented and clearly understood attempts by the doctor to discuss the issue with the

patient, as well as attempts to rectify the situation. Many doctors' offices have a protocol for discharging a patient (even though it usually occurs very infrequently). The doctor should make a full effort to explain his/her concern to the patient and document each such attempt. The attempts must be in clear, non-medical terms, so that the patient understands the issues. Following these attempts, a formal termination may ensue.

Can a doctor fire me for personal reasons?

A doctor cannot terminate a patient on the basis of his or her gender, race, religion, or sexual preference. Additionally, in 1998, the United States Supreme Court ruled in Bragdon v. Abbott that asymptomatic HIV is a disability included under the Americans with Disabilities Act (ADA) of 1990. This case involved a dentist's refusal to fill a cavity of an asymptomatic HIV patient in his office, although the dentist was willing to treat the patient in a hospital at a higher cost to the patient. The patient sued the dentist and argued a violation of the ADA. The Supreme Court's decision discusses health care providers' legal obligations to treat HIV-infected patients, as well as patients with other disabilities.

Similarly, the AMA's Council on Ethical and Judicial Affairs has found it unethical to deny medical treatment to HIV-positive individuals.

On what grounds can my doctor fire me?

All in all, very few doctors ever terminate a patient; in fact, they often take multiple steps to avoid ever having to face this decision. Part of the phenomenon relates to a doctor's loyalty to patients. In addition, with the rising cost of medical liability premiums, it can become a significant financial issue. For instance, office expenses have caused many practices to accept more and more patients in order to remain financially viable. This may be further compounded in the future for certain specialists as reimbursement models are changed.

A patient may be fired from the practice for harmful and dangerous behavior toward the office staff and other patients. Some patients may become angry with their disease, diagnosis, and difficult situations, and unfortunately, it is not uncommon for them to take it out either on the doctor or the office staff. Doctors in private practice are committed to create a safe working environment for their staff and other compliant patients, and so this type of behavior is understandably not tolerated.

A patient may also be expelled from the practice for repeated non-compliance with a doctor's instructions or office policies. A patient who repeatedly refuses to follow up on medical tests, radiographic examinations, sub-specialist referrals, etc. may in fact compromise the level of care delivered by the doctor and result in the doctor's insistence that the patient comply or else seek medical attention elsewhere. However, each of these events and concerted efforts to educate the patient and impress upon him or her the importance of these medical consultations/tests should should be clearly documented. Even with these efforts, if the patient is still non-compliant, good medical care is compromised.

Sometimes a patient may be dismissed from the practice for not paying his/her bills. A doctor may also be confronted with a patient unwilling or unable to pay medical bills. There is no uniform standard adopted by the courts regarding whether a patient's inability to pay or lack of insurance justifies a doctor's termination, especially when the patient continues to receive medical treatment. However, some private offices may have financial policies of which patients are notified from the very beginning and to which the office will adhere.

A patient should also expect the doctor to deny care when a patient requests services outside the doctor's area of expertise or office hours, or at a location other than the doctor's office or hospital where the doctor has admitting privileges. In non-emergency situations, a doctor is generally justified in refusing to treat unruly and uncooperative patients.

Finally, if a patient is found to have altered a written prescription, the physician should confront the patient and seek an explanation for this behavior. The patient may be asked to seek medical assistance elsewhere. This patient behavior is not only illegal (when prescriptions are used for distribution and financial gain), but also unethical, and violates the implicit trust a doctor has in his/her patients.

Conclusion

The doctor-patient relationship is a special bond between the two individuals. A patient, while having more flexibility to terminate the relationship, should act in a professional and prudent manner. Once the relationship is established, the doctor is limited in the ways and reasons that he or she can terminate the relationship with a patient.